Ussery Roan Texas State Veterans Home

In the surveyor’s words

From the most serious findings on record at Ussery Roan Texas State Veterans Home, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jul 5, 2023

  Based on interviews, observation, and record reviews, the facility failed to ensure the right to be free from abuse was provided for 1 of 8 residents (Resident #2) reviewed for abuse. LVN A was observed striking Resident #2 on his upper arm/shoulder after resident had grabbed LVN A's right breast. An Immediate Jeopardy (IJ) was identified on 6/13/23 at 5:00 PM and the IJ template was provided to the facility Administrator on 6/13/23 at 6/13/23 at 5:00 PM. While the immediate jeopardy was listed on 6/14/23 at 8:00 PM, the facility remained out of compliance at a scope no actual harm with potential for more than minimal harm: and a severity level of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. […]

• Immediate jeopardy, isolatedF689Apr 11, 2025

  Based on observations, interview and record review, the facility failed to ensure the residents environment remained free from accidents as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 12 residents (Resident #1) reviewed for accidents, hazards, and supervision. The facility failed to ensure Resident #1 did not elope from the facility. The noncompliance was identiified as Past Non-Compliance. The Immediate Jeopardy began on 3/7/25 and ended on 4/3/25. […]

• Actual harm, isolatedF689Aug 4, 2022

  Based on interviews and record review, the facility failed to ensure the resident environment remains as free from accidents hazards as is possible, and each resident received adequate supervision and assistance to prevent accidents for 1 of 10 residents (Resident #1) reviewed for safety and supervision. TA A failed to properly secure wheelchair bound Resident #1 in the facility van resulting in the resident falling out of the wheelchair which resulted in a fracture. This failure could affect residents at the facility by placing them at risk for accidents that lead to injuries. […]

• No harm, potential for more than minimal, widespreadF812Mar 22, 2024

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure general sanitary conditions in the kitchen were maintained during preparation and serving of food. 2. The facility failed to ensure hairnets and beard covers were worn. 3. The facility failed to ensure the food items were properly stored, labeled, and dated. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: In an interview and observation on 3/4/24 at 8:15 am Cook A was observed in the kitchen preparing food with no beard cover. […]

• No harm, potential for more than minimal, widespreadF812Nov 19, 2021

  Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service standards in 1 of 1 kitchen reviewed for food safety. The facility failed to: A. Ensure foods were stored, prepared and served under sanitary conditions in the kitchen. B. Ensure general cleanliness was maintained in the kitchen. This deficient practice has the potential to affect residents by causing food-borne illnesses, weight loss, and a diminished meal experience. Findings include: In an observation on 11/17/21 at 8:20 AM on initial kitchen rounds the walk- in freezer, the following was noted: 1. The floor had trash and food debris in the walking pathways and under the shelving units. 2. […]